Religious Accommodation Form

Student Information

Date of incident(Required):

This field is required.

Campus(Required):

This field is required.

Involved Parties

Student Name

Student Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Davenport Email address

Questions

Information provided to Davenport will help the University work with students to plan effective academic accommodations and auxiliary aids and services while enrolled. All information provided on a voluntary basis by a student shall be used for the sole purpose of assessing the accommodation request(s).

Please select your area of study:(Required)

College of Business College of Health College of Technology Other

This field is required.

Please describe the accommodation you wish to be granted below:(Required) This field is required.

Please describe how your deeply held and personal religious beliefs directly relate to the inability to receive the COVID-19 Vaccination specifically, and/or other vaccinations from which you are requesting an exemption. Be sure to include specific details surrounding your deeply held and personal beliefs.(Required) This field is required.

Have you received other vaccinations in the past? If not, please say no. If you have, please describe how the requested exemptions would differ.(Required) This field is required.

What semester are you looking to receive this accommodation in?(Required)

Fall Winter Spring/Summer

This field is required.

Supporting Religious Documentation

If you are inclined, you may attach additional supporting documentation from your religious affiliation or spiritual leader to serve as further insight to your request. This additional documentation may not replace the need for the requested personal statement that is sincerely held by the individual above. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Student Information

Involved Parties

Questions

Supporting Religious Documentation

Submission